Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of biopsy-proven Class III Focal Proliferative Lupus Nephritis (ICD-10: M32.14). Current symptoms include [hematuria/proteinuria/edema]. Review of systems positive for [fatigue/arthralgia/malar rash]. Renal function stable/declining with recent creatinine of [X] mg/dL and UPCR of [X] g/g. Adherence to immunosuppressive regimen is [good/poor].
Clinical Examination Findings
Patient appears [well/ill-appearing], alert and oriented x3. Vital signs: BP [X/X] mmHg, HR [X] bpm. Physical exam reveals [trace/pitting] peripheral edema in lower extremities. No signs of acute distress. Skin exam: [malar rash/discoid lesions] noted.
Treatment Protocol
Initiate/Continue induction therapy with [Mycophenolate Mofetil/Cyclophosphamide] and high-dose corticosteroids. Monitor for adverse effects including infection, cytopenias, and GI distress. Target BP <130/80 mmHg with ACE inhibitor/ARB therapy. Maintain strict adherence to immunosuppression to prevent progression to Class IV.